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WORK UPS AND MANAGEMENT
Traditional and New Diagnostic Approaches
DIAGNOSTICS APPLICATIONS
Traditional approaches
- Symptom-based-TST-TB Culture-- AFB smear-- Chest radiograph
Probable active TBEvidence of MTB InfectionBacteriologic Confirmation of active TB
Probable Active TB
New Diagnostic Approaches
ORGANISM BASED-Colorimetric cultures systems-- phage based test
-- Microscopic- based observation drug susceptibility (MODs) assay
Bacteriological confirmation of active TBProbable active Tb and detection of rifampin resistanceProbable active TB and detection of resistance
Traditional and New Diagnostic Approaches
DIAGNOSTICS APPLICATIONS
New Diagnostic Approaches
ANTIGEN BASED ASSAYS-LAM detection assayIMMUNE BASED ASSAY-Antibody based assay--MPB-64 skin test-- T- Cell assaysSYMPTON BASED-Symptom based screening-Refined symptom based Diagnosis
Probable active TB
Probable active TBProbable active TBDiagnosis of Latent TB infection
Screening child contacts of adult TB casesProbable Active TB
Diagnosis of TB
• A positive culture with or without a positive smear for M. Tuberculosis is the gold standard for the diagnosis of TB
In the absence of bacteriologic evidence , a child is presumed to have active TB if > 3 crteria are present:
• Exposure to an adult/Adolescence with active TB (EPIDEMIOLOGIC)
• Signs and symptoms suggestive of TB (CLINICAL)• Positive tuberculin test (IMMUNOLOGIC)• Abnormal chest radiograph suggestive of TB (RADIOLOGIC)• Other lab findings suggestive of TB (LABORATORY)
OUR PATIENT
• TST – 12 mm induration• Chest X –ray showed evidence of primary
infection• Signs and symptoms of TB
Chest X- ray of the patient 11/24/10
The heart is not enlarged. There is slight haziness over the right lung base and the retrocardiac region, with nodular densities over the retrocardiac region, which may be due to lymph nodes. This may represent primary infection.Both hemidiaphragm and sinuses are normal. The visualized osseous structures are unremarkable. 11/24/2010
Management of Tuberculosis
Objectives of Drug Therapy in TB:
1. Cure the patient of TB2. Prevent death from active TB 3. Prevent relapse of TB4. Prevent the development of drug resistance5. Decrease transmission
Phases of Treatment
• Intensive Phase - efficient killing of actively dividing organisms- relief of symptoms- terminates transmision- prevents emergence of drug resistance
• Continuation Phase - kills irregularly dividing bacilli- sterilizes lesions and prevent relapse
Drug Administartion
• The optimal dosing frequency for new patients with pulmonary TB is daily throughout the course of therapy.
Alternative Regimens:(1)A daily intensive phase followed by tree times
weekly continuation phase [2HRZE/4H3R3] , provided that each dose is directly observed
(2)Three times weekly dosing throughout the therapy [2H3R3Z3E3/4H3R3] , provided that every dose is directly observed.
Essential Anti-Tuberculosis DrugsDRUG MOA DOSE RANGE
Single daily dose mkd
3X weekly mkd
INH -Bactericidal agent--Acts on extracellular and intracellular bacillary populations-- presumed to inhibit biosynthesis of mycolic acid (cell wall component ) and effects glycolysis , nucleic acid synthesis
10 -15 Max 300 mg
20-30Max 900 mg
Rifampicin -Bactericidal agent--Acts on extracellular and intracellular bacillary populations-- inhibits nucleic acid synthesis
10-20Max 600 mg
10-20Max 600 mg
Essential Anti-Tuberculosis DrugsDRUG MOA DOSE RANGE
Single daily dose mkd
3X weekly mkd
Pyrazinamide -- weak bactericidal but with potent sterilizing activity within macrophages, areas of acute inflammation
20-40Max 2 g
50 mgMax 2 g
Streptomycin - Bactericidal 20-40 max 1 g
Ethambutol -Bacteriostatic, but with some bactericidal action at higher doses -- acts on intra and extracellular bacillary populations-- presumed to inhibit synthesis of mycolic acid (cell wall component)
15- 25 Max 1.2 g
30-50Max 2.5 g
Essential Anti-Tuberculosis Drugs
DRUG ADVERSE REACTIONS
INH -- peripheral neuropathy-Other neurological disturbance, optic neuritis, toxic psychosis, generalized convulsions-- systematic or cutaneous hypersensitivity reactions during the first week of treatment-- hepatotoxicity
Rifampicin -Gastrointestinal intolerance-- if intermittent adminidtration: rash , fever, thrombocytopenia, flu like symptoms-- increases risk of hepatotoxicity if used with INH
Pyrazinamide -- hypersensitivity reactions--moderate rise in trasaminase levels -- Hyperuricemia-- arthralgia, particularly of shoulders
Essential Anti-Tuberculosis Drugs
DRUG ADVERSE REACTIONS
Streptomycin
-- sterile abscess-- vestibular, auditory function impairment-- hemolytic anemia
Ethambutol
-- retrobulbar neuritis ( reduced visual acuity, contraction of visual fields, green red color blindness)
TREATMENT
21 kgIsoniazid 200 mg/5mL (10 mkd) – 5.5 mLRifampicin 200mg/5mL (10 mkd)- 5.5 mLPyrazinamide 500 mg/5mL (20 mkd) – 4.5 mLEthambutol 400 mg/tab (20 mkd) - 1 tab